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Cognitive-Behavioral Therapy

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.

The marriage of cognitive therapy and behavioral therapy has been a significant change in psychology. Each approach has somewhat different methods. Nonetheless, they both are scientific methods that alter thoughts and behaviors interfering with someone's functioning, and enjoyment of life. It is generally assumed there is a bi-directional causality between behavior and cognition. This means behavioral change leads to cognitive change, and cognitive change leads to behavioral change. Thus, nowadays few clinicians rely on a single approach. Instead, they employ a blend of both cognitive and behavioral techniques. For example, some therapy participants benefit from a few sessions of cognitive therapy before jumping into the more challenging, behavioral method of exposure and response prevention (ERP).  By decreasing certain dysfunctional beliefs, the therapy participant can more readily tolerate the initial discomfort of ERP. Many studies have found that the combination of these techniques, along with the appropriate medication, can produce the greatest treatment benefit for many of the anxiety disorders (Franklin & Foa, 2007).

As you have already learned, cognitive-behavioral therapy (CBT) is supported by a large body of research. In an attempt to standardize treatment, the American Psychological Association (APA) formed a task force. The APA charged the task force with the responsibility of developing a list of empirically supported treatments for psychiatric disorders. The APA encouraged the development of treatment protocol manuals. This would ensure that people received the best possible care using standardized, efficacious treatment practices. The APA's task force had numerous requirements before a therapy could be approved as an empirically supported treatment. One such requirement was stringent, controlled, research studies consisting of standard scientific methods. Cognitive-behavioral techniques are consistently identified as the most effective type of treatment for anxiety disorders (Deacon & Abramowitz, 2004; Norton & Price, 2007; Stewart & Chamblass, 2009).

Hybrid Therapies

Overtime, the cognitive-behavioral model has been revised and further modified. One modification was to integrate CBT with other theories. This integration resulted in several effective hybrids of CBT. These hybrid therapies cannot be considered cognitive-behavioral therapies (CBT) in the strictest sense. Nonetheless, they rest heavily on the CBT foundation.

Two such therapies have been successfully applied in the treatment of anxiety disorders: Acceptance and Commitment Therapy (ACT), and Dialectical Behavioral Therapy (DBT). Both of these therapies have modified the strong emphasis on change that is inherent in conventional CBT.

Acceptance and Commitment Therapy (ACT)

For those people who are reluctant to enter exposure and response prevention therapy, there is another approach that has recently attracted a lot of attention. It is called Acceptance and Commitment Therapy (ACT). ACT is derived from functional contexualism and relational frame theory. While these concepts are highly abstract and quite complex, they can be distilled down to one essential feature. ACT recognizes that words (and the thoughts formed with words) have individual and unique meanings. This unique meaning is dependent upon the specific person and context in which the learning took place. The overall message of ACT is that the meaning and importance we assign to our thoughts, perpetuates our emotional suffering. While ACT is very similar to traditional cognitive-behavioral therapy (CBT), it differs in that it accepts and embraces dysfunctional thoughts. Instead of attempting to challenge and correct dysfunctional thoughts (as would conventional CBT), therapy participants are encouraged to view these thoughts dispassionately. So instead of attempting to challenge and correct the dysfunctional thought, "Everyone thinks I'm ugly," the person detaches from the meaning of the thought. This would become, "I'm simply having a thought that everyone thinks I'm ugly." This shift in perspective places thoughts in their proper perspective. Thoughts are just that. They do not represent facts. They have no particular meaning other than the meaning we assign to them.

Because language allows us to attribute meaning to thoughts, it is possible for us to allow thoughts to enter our minds without giving them importance. ACT teaches people how to accept their emotional distress. Simultaneously, they are encouraged to build a meaningful life that is anchored to their value system, rather than a life that is dictated by their symptoms. For example, in the case of Social Anxiety Disorder (Social Phobia), therapy participants might be asked to examine the enormous value they place on the opinions of other people. They would be asked to consider other values that are important to them. Having identified other important values, therapy participants commit to actively pursuing a life that models these values. Therapy participants also learn to tolerate emotional pain through mindfulness training and meditation exercises. These exercises aim to make people aware of their thoughts, feelings, images, and memories without judgment or avoidance. Incorporating ACT into cognitive-behavioral treatment for anxiety disorders may be a valuable tool to decrease the poor quality of life, high suicide rates, depression, and immense suffering reported by people with anxiety disorders (Eifert, Forsyth, & Hayes, 2005).

Dialectical Behavior Therapy (DBT)

Dialectical behavior therapy (DBT) was developed by Marsha Linehan in the early 1990s. Her initial focus was the treatment of highly suicidal, female patients diagnosed with Borderline Personality Disorder. Since its initial development, its application has been successfully expanded to include other disorders. DBT is rooted in scientifically supported, cognitive-behavioral techniques. However, it integrates an Eastern philosophical approach of acceptance and mindfulness meditation. Dr. Linehan found that the heavy emphasis on change, inherent in cognitive-behavioral methods, was problematic for many therapy participants. For these people, this emphasis on change invalidated their experience and discounted their suffering.

The term "dialectic" refers to the synthesis of two opposing facts or ideas. Thus in DBT, the dialectic is between change and acceptance. The goal of DBT is to help therapy participants find the balance between these two contradictory ideas. Other dialects are: work and play, emotions and reason, and fulfilling one's needs vs. fulfilling someone else's needs. DBT uses a combination of individual therapy along with structured, skills training groups. Participants are taught skills that enable them to: 1) better regulate their intense emotions; 2) become more effective in their interpersonal relationships; 3) improve their ability to cope with emotional crises; and, 4) decrease their reliance on unhealthy coping behaviors such as substance abuse, self-injury, and suicidal behaviors.

Dialectical behavior therapy may be beneficial for persons who are reluctant to engage in exposure and response prevention therapy (ERP). This initial reluctance may occur because people are unwilling or unable to tolerate the inherent, but temporary, discomfort associated with ERP. DBT may also be applied as an adjunct treatment for people with co-occurring disorders. For instance, DBT can be very helpful for people with anxiety disorders and Borderline Personality Disorder. Similarly, DBT is useful for people who have compulsive hair pulling (trichotillomania) These disorders commonly co-occur with some of the anxiety disorders. For more information see our topic center on Obsessive Compulsive Spectrum Disorder (coming soon).